A Look Into Preventive Medicine With A Residency Director

Session 137

What makes a great preventive medicine physician? Dr. Patrick Remington, Director of the University of Wisconson-Madison Preventive Medicine Residency Program, answers! He’s a preventive medicine specialist and a program director at the University of Wisconsin for preventive medicine.

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Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points.

[00:35] A Source of Motivation

We are in the middle of our COVID-19 pandemic. I hope you are all safe, hanging out at home, just going out to as little as possible. That’s what I’ve been doing now for 19 days as I record this, so my thoughts are with you. I hope you’re all safe.

You are seeing what it’s like to be a physician in this country. You are seeing how the world responds, how the United States responds, and how physicians respond to pandemics, to illness to injury, right out in the news every day.

Hopefully, this motivates you even more to becoming a physician. And for some of you, it may discourage you, and that’s okay too. If you’re a premed, if you’re a medical student, and that’s discouraging, then we should talk. Email me [email protected].

Back to our episode today, we have a great discussion about preventive medicine, what it is and how he got into it. As a program director, he talks about what makes you stand out as an applicant, which is always important.

[01:32] Interest in Preventive Medicine

It was during medical school that Patrick was interested in primary care. He wanted to go overseas to do international or global health elective. Unfortunately, that elective was canceled due to civil unrest in Zaire.

He had to scramble in his fourth year to find another rotation that would make up for his global health rotation.

At that time, a friend was working up at the health department who was a physician and doing public health stuff. Patrick was invited to come over so he quickly organized the fourth year one-month elective. He took the seat of somebody who had been assigned to the State of Wisconsin for the Epidemic Intelligence Service. He was out of the country in Somalia so he took his seat.

For one month, he was acting like a CDC assigned Epidemic Intelligence Service Officer and this just really piqued his interest.

He worked on an outbreak of a fungal infection called sporotrichosis. He worked on a person to person spread of typhoid fever in a community. He got excited aboutlooking at infectious diseases, thinking about a community-wide approach, and working with the media who were concerned about these.

At the end of that rotation, he was very intrigued with what a physician might do in the practice of public health. It practically took him a month to convince himself that it was something he would be interested in.

[04:15] A View on Public Health

This outbreak, global, potentially, global pandemic, is bringing preventive medicine right to the public’s eye.

It’s clearly the whole concept of preventive medicine and public health where these specialists do work behind the scenes. They work on programs and policies, often laws and rules and regulations that provide an opportunity or an environment for people to be healthy.

This could include things like safe water restaurants that are inspected and immunization programs.

When you’re involved in patient care, either as a medical student, resident or practicing physician, your assumption is that these are just in the background keeping communities healthy, keeping patients healthy.

And when an outbreak comes, that’s when people, clinicians, and the public become aware of public health.

But in a way, when public health physicians are doing their job, they’re not making the front page of the newspaper. They’re working in the background, doing the things that they need to do to keep people safe, whether be at work, or at school or whatever.

[07:01] Lack of Awareness to the Specialty

Oftentimes, when you look at a list of specialty options that medical students are provided, it’s not even on the list.

It’s generally considered to be a non-clinical residency, although now the current requirements do require continued clinical training. And it’s just there aren’t a lot of faculty in medical schools who have teaching opportunities for medical students. There aren’t required rotations.

[09:06] The 3 Subspecialties of Preventive Medicine

Aerospace medicine comes from the roots of military issues. They deal with very specialized medical issues related to aerospace and undersea medicine.

Occupational medicine as a subspecialty where they see patients usually in a worksite. They not only see patients, but most importantly, develop programs and policies within the worksite that keep people healthy. They think about worker safety. They think about occupational injuries, exposure assessment, and providing safe workplaces.

Large companies will hire occupational medicine physicians while some clinics will develop programs that provide services to work sites.

General preventive medicine and public health is oftentimes not involved in patient care per se. They see the entire community rather than individual patients. When Patrick began his training program at the CDC, he was doing a two-year epidemiology fellowship called the Epidemic Intelligence Service. It did not involve individual patient care.

[10:52] The Need for Patient Care

During his training, Patrick would occasionally see people during an outbreak investigation. He might do an exam. But his role was to think about common exposures and how sick people are compared to those who weren’t. They’d identify an agent and then implement some prevention program.

So that two-year planning training program really focused on epidemiology and public health, as opposed to individual patient care.

For his residency, he continued on it at CDC and did their preventive medicine residency, which similarly had no patient care component.

Many of the physicians who trained in preventive medicine in the subspecialty of general preventive medicine and public health were not seeing patients. This was either during their training program or during their career.

But that has changed about five years ago. The college and the residency review committee have brought back a clinical requirement for residents. That is about two months of patient care per year about one day a week.

The idea is to mandate during a training program that residents keep their clinical skills up. At the end of your residency, should you decide to go into primary care in an underserved area, or into a position that had a one or two day days in the clinic, you would still have maintained your clinical competency.

Patrick spent six years at CDC doing the Epidemic Intelligence Service, preventive medicine, and then a career development program. Then he came back to his hometown of Madison, Wisconsin. He worked at the state health department as a chief medical officer for chronic disease and injury prevention.

Patrick had spent nine years at the state health department practicing public health. He was not seeing patients but working on tobacco prevention, cancer prevention, diabetes prevention.

At the end of that period, he looked at joining the university. Because he was really interested in a faculty position that involved developing public health education programs and public health research, he then went to the University. He realized he was back at his medical school where he got his medical degree.

Funny story:

Being a preventive medicine physician, he told himself he was going to teach a course, a one-credit elective in the evenings. It’s called Physicians in Public Health.

Patrick posted an advertisement and there wasn’t a lot of interest. So then he reissued the posting and said –free pizza! With that free pizza, he was able to get about 20-25 students to come and listen to physicians who worked in public health. The pizza made a big difference!

The feedback he got from students was that the specialty really didn’t resonate with them. It wasn’t interesting enough. It’s not why they came to medical school because they want to see patients.

So what Patrick did was he brought a physician who was very active as a clinician but did public health as well. She worked about three to four days a week as a clinician. But in her spare time, she led programs in global health and community health.

He then changed the name of the course to Physicians in Medicine and Public Health. Currently, this elective has 80 to 105 students each year, about half of the medical school class takes it. It’s very popular.

[16:53] Promoting Medicine and Public Health

After a few years of this experience, the school actually changed its name from the University Wisconsin Medical School to the University of Wisconsin School of Medicine and Public Health.

It’s not a school of public health, it’s a medical school, but in its name, and its mission is medicine and public health. They train medical students to be physicians who are outstanding clinicians, but also know how to take care of communities.

As a result, the communities where they live or work are as healthy as they can be so they can be better physicians. He isn’t buying any pizza this time around. But they come because of interest in doing medicine and public health.

Patrick encourages students to see preventive medicine as either a specialty or something the can combine with their clinical specialty. So they’re not only taking care of patients, but also they’re thinking about the context in which they live.

If that’s really what drives you to get up in the morning to think about better ways to prevent disease, then what you’re beginning to think about is preventive medicine.

That’s not saying you shouldn’t be spending time taking care of the patients. We need outstanding clinicians.

That being said, physicians are in a great position to help communities with policies and programs that can really be effective than making where you live a healthy place. Then also they get to spend time seeing patients and getting the benefits of direct patient care.

[22:57] Message to Primary Care Physicians

Patrick encourages primary care physicians to recognize that there is this entire public health system out there. Many primary care physicians know that. You’ll often see a patient who has an infectious disease. And that needs to be reported to the public health department to do contact tracing.

You need to have a partnership with your local health department, many of which have physicians as medical advisors. So you would understand how to do isolation and quarantine and really take a public health approach.

The other thing is, if you find yourself as a primary care physician, dealing with an obese kid, who you know is struggling. And mom and dad just don’t seem to be able to figure this out. Think about what’s going on in the community that we could do better with to help kids lead healthy and active lives.

Patrick also encourages primary care physicians to understand that public health is in someone’s job description. There are physicians in communities who are trying to work on those. So reach out and find people who are working in public health and offer your assistance.

For example, schools need to be places where kids get healthier and educated, not where they sit in a seat for eight hours and learn. But they don’t really learn about healthy living.

So you have to understand there are people out in the community and that they can partner with them and be of great assistance.

[26:28] The Most and Least Liked Things About Preventive Medicine

Patrick really loves the dynamic nature of it. Public health challenges are wicked health problems, as the CDC Director called them. They are incredibly complex.

Just think about the opioid epidemic, its origins, the methods for control prevention and control. We have tremendous patient care challenges. But thinking about the opioid epidemic, that wasn’t a concern 10 years ago. We didn’t have awareness of the problems that were present in communities that led to physicians prescribing opioids and patients seeking them. Then all of a sudden we have this tremendous opioid epidemic.

Another example is childhood obesity, what an incredibly complex problem, which is not going to be solved in the clinical setting. And then adolescents and adults with morbid obesity, the rates of morbid obesity, body mass indexes of 40, 50, 100. Those are now common in society and how are we going to solve that problem?

Patrick has worked on a lot of these issues with communities and with state health department. He’s thinking about how he can help communities structure what we call a sure condition so that people can live long and healthy lives.

Although he’s solving complicated problems, Patrick likes the fact that it involves communicating with the public and with practitioners and with policymakers. This was something he was interested in earlier on.

Now, he’s teaching a course in communicating public health information effectively. They teach medical students who are doing a dual degree and other MPH students, and their preventive medicine residents how to really become effective communicators. How do you do it with mass media, with journalists, with community groups? How do you do a radio interview? And or a podcast?

Patrick thinks it would be great for all people trained in preventive medicine to be able to participate in their community, bring people together, and share information and really build a culture of health.

On the other hand, what he likes least are the meetings. Patrick reveals they spend a lot of time in meetings. But meetings are really important because there are lots of things to talk about. You bring diverse groups together.

He spent 10 years as the Associate Dean for Public Health. It was a position they created in medical school when they transformed into a school of medicine and public health. There were a lot of opportunities for him to meet with people to talk about public health. And it’s a necessary part of the position.

[30:18] Developing the County Health Rankings & Roadmaps

Patrick’s favorite projects are where they look at data and information and figure out how to communicate it.

One of his brainchild projects is the County Health Rankings.

While he was at CDC, they developed a program called the County Health Rankings. He noticed that when they published the list where they ranked the health of states, people paid attention.

In fact, when he ranked states from healthiest to least for heart disease, the Senator from Michigan did not take kindly to the fact that his state was ranked last. He then threatened the CDC director with eliminating the budget if they ever ranked again.

So they developed a state health accounting health ranking and Wisconsin did that for about six years. Ultimately, Robert Wood Johnson Foundation saw that and then developed the national program where there were 50 County Health rankings in all 50 states. Now, they’re coming into their 11th year actually, and it’s released every March.

Check out County Health Rankings for your state to see how the health of your immunity compares to the health of others. This embodies Patrick’s passion for using information on the health of an entire community to figure out how healthy your community is.

Consequently, they were accused of just ranking them and spanking them because they didn’t initially offer a helping hand. So a year or two into this program, they have developed the roadmaps program that goes along with the rankings.

The roadmap consists of evidence-based programs and talks about the coalition approach, which they call the Action Cycle for a Healthy Community.

Although it’s under new leadership now, that was a program Patrick worked on for a decade. And he feels grateful to see something from almost losing his job at CDC into a way to call attention to the health disparities and inequities we see within each state.

[33:53] Public Health in the Medical School Curriculum

Patrick admits it’s hard to learn how to be a clinician because it requires a lot of work. Then also you’re thinking about what type of specialty. Then when you’re a fourth year student, the curriculum is packed. It’s really hard to step back and insert a program about policy process or about epidemiology.

By and large, you can get away training medical students to be outstanding clinicians without much public health content.

One thing is the competition for what it takes to train outstanding clinicians. Because we all want our physicians to be outstanding clinicians in diagnosis and treatment. So Patric sees this as a challenge.

Many programs have said that to really do a good job, if you want to be a physician trained equally in preventive medicine and clinical medicine, you should probably take an extra year and do a dual degree program.

So students will have to take an extra year. There are downsides to that because it means extra tuition, there’s another year of training, there’s time away from your medical training. So there are challenges. But many medical students will still do this. Because they are interested in not only being outstanding clinicians, but doing more for their patients and communities.

[36:17] Final Words of Wisdom

Preventive medicine embraces a set of competencies. And those competencies really sort of begin where the patient interaction ends. And so if you find yourself thinking, how would I get recess back into the school, think about what it would take to do that. Think about what it would take to create an environment for your patients to be healthier.

From defining the problem using epidemiology to finding programs that work, getting people together in coalitions and understanding how policy happens and going to meetings occasionally and being part of the process – those are the things you could learn along the way.

If you have a day of patient care but you’re really interested in doing more community work after. You want to figure out ways to keep communities healthy and work in partnership. You want to spend a couple of days or even your entire career on that, then Preventive Medicine is the specialty for you.

Some people come to that decision after full training in family medicine. But if it comes to you during medical school or during clinical residency. You would like to focus on a balanced portfolio or maybe just spending all your time doing work in communities. It’s not only involving day to day patient care but thinking about how to change communities to be healthier. Then look at the American College of Preventive Medicine website.

Look at residency programs in your state or in your region. Knock on the door of a preventive medicine doctor and talk to him or her about what they do every day. You’ll find that it’s a great variety.